Islamic Perspectives on Organ Transplantation: a Continuous Debate

religions

Article Islamic Perspectives on Organ Transplantation: A Continuous Debate

Jan A. Ali

School of Humanities and Communication Arts, Western Sydney University, Penrith, NSW 2751, Australia; [email protected]

Abstract: From a medical perspective, as well as an ordinary human perspective, organ transplantation is often understood as a process through which health is restored to sick humans and, consequently, their quality of life improved. Organ transplantation is a medical surgical procedure carried out by an expert or a team of experts who remove a failing or diseased organ or organs from the human body and replace it or them with a functioning organ or organs. With such positive portrayal of the process, organ transplantation is highly recommended and encouraged in modern medicine. However, in Islam, the Qur’an and hadiths—the two great texts of the religion—are silent on the subject. In other words, there is no discussion of the subject in the texts and, therefore, it is not clear whether organ transplantation is permissible or not in Islam. Thus, is organ transplantation an accepted modality of treatment that eliminates the patient’s agony from end-stage organ failure, remains an open-ended question. Whilst some Muslim scholars and jurists argue in favour of organ donation and transplantation, there are others who reject the practice as a breach of shari’ah. This paper posits that the subject of organ donation and transplantation in Islam is an unresolved matter without a ubiquitous consensus. The purpose of the paper is to educate the readers about the two key perspectives on the subject, and highlight that more research and a robust academic and sociological debate are needed to resolve the question of organ donation and transplantation in Islam.

Citation: Ali, Jan A. 2021. Islamic Keywords: organ transplantation; Islam; Qur’an; hadiths; shari’ah; modern medicine Perspectives on Organ Transplantation: A Continuous Debate. Religions 12: 576. https:// doi.org/10.3390/rel12080576 1. Introduction

Academic Editor: Terry Lovat Recent medical advances made in the fields of organ procurement and organ transplantation have brought about new treatment regimes in patients and better management and Received: 29 June 2021 even cure of diseases. The West has become the leader in this medical field, making great Accepted: 22 July 2021 strides in disease control, management, and cure through a variety of medical means and Published: 27 July 2021 surgical procedures, including organ and tissue transplantation. With the advancements made in modern western medicine and technological innovations, organ transplantation is, Publisher’s Note: MDPI stays neutral for the first time in human history, taking place on a mass scale. Organ transplantation is a with regard to jurisdictional claims in medical surgical procedure undertaken by an expert or a team of experts who remove a published maps and institutional affil- failing or diseased organ or organs (or parts thereof) from the human body and replace it or iations. them with a functioning organ or organs. Although the transplantation in the modern era started in earnest in the 1940s (Scott 1981, p. 19) it was not until the discovery of effective immunosuppressive drugs in the late 1970s that the medical experts began to achieve great success in bone marrow, kidney, liver, thymus, cornea, pancreas, lungs, heart, intestine, Copyright: © 2021 by the author. uterus, and nerve cell transplantations, rendering organ transplantation a medical routinal Licensee MDPI, Basel, Switzerland. activity in the late twentieth and early twenty-first centuries. The surgical procedure is This article is an open access article performed to cure a disease and prolong life. In modern medicine, three types of organ distributed under the terms and transplantation are practiced: conditions of the Creative Commons i autograft or autotransplantation; Attribution (CC BY) license (https:// ii allograft or allotransplantation; creativecommons.org/licenses/by/ 4.0/). iii xenograft or xenotransplantation.

Religions 2021, 12, 576. https://doi.org/10.3390/rel12080576 https://www.mdpi.com/journal/religions Religions 2021, 12, 576 2 of 16

The surgical procedure is performed to alleviate suffering, cure end stage disease, and prolong life. However, organ transplantation, certainly, is not a new phenomenon. In fact, autografting as a form of organ transplanting technique is a prehistoric phenomenon. Ancient Hindu surgeons used to apply it to repair noses damaged, for example, by syphilis, and ear defects caused, for instance, in warfare, using the neighbouring skin. The procedure is described in the classic Sanskrit text on medicine written by Susruta Sanhita in 6th century BC (Zhorne 1985, p. 10). However, the sociological and anthropological study of this phenomenon, particularly in the context of Islam, is one of the most under-researched areas. In Islam, organ transplantation and donation are not specifically discussed in the scriptures, namely the Qur’an and Hadith. Both of these two great texts of Islam are silent on the issue of organ transplantation and donation, and the debates surrounding organ transplantation and donation are only recently beginning to surface in Islamic scholarship (Ali 2019, p. 59). The Qur’an, Sunna (sayings and actions of Prophet Muhammad), and shari’ah (Islamic law) collectively have not addressed the question of organ transplantation, therefore interpretations and fatwas (nonbinding rulings on a point of Islamic law offered by a qualified jurist or a recognised authority) abound, and a unitary singular Islamic response to the topic remains absent. Additionally, as Islam differs from a Catholic papacy-type central authority, where doctrinal authority is centralized in the papacy, decision making in Islam takes place within the framework of multiple authorities with the ulama (religious scholars) and fuqaha (jurists) having important roles to play. Generally speaking, instructions can be found in Islam that direct its adherents to protect the body at all times and accord it care and attention during illness. Protection of the body and its treatment during illness is directly linked with the idea of preservation of life and account for a good deed. Many Islamic scholars, in light of this, view organ transplantation permissible in Islam. However, not all Islamic scholars and jurists necessarily agree with organ donation and transplantation. They consider organ transplantation and donation to be prohibited in Islam. Currently, no general consensus exists among Muslim scholars, including Muslim jurists, in the context of a specific Muslim-majority country or globally, on permissibility or impermissibility of organ donation and transplantation. The opinions are divided and can be located in one of the two overarching categories: i permissibility; ii impermissibility. Given the fact that the two great texts of Islam—Qur’an and hadith (recorded sayings and actions of the Prophet Muhammad)—as well as the shari’ah are silent on the issue of organ donation and transplantation, how, then, does Islamic faith reconcile itself with the progress and advancements made in different fields, including medicine, by humanity in time and space, i.e., in modernity? More specifically, how does Islamic faith engage with organ transplantation debates and practices? These are important questions in the sociology of Islam. It is important to note that organ donation and transplantation in their current forms are modern medical developments, born out of new scientific and medical discoveries and progress made not in Islamicate, but outside it, in the West. Muslims who have to face the possibility of having organ transplantations or making organ donations not only have to pay heed to Islamic theology and legal precepts, but also have to deal with the deep and extensive effects of organ transplantation involving donors, recipients, families, and medical professionals. Organ donation and transplantation, therefore, is not only a “private transaction” between the donor and recipient, but one that occurs within the context of an intricate nexus of relationships extending to incorporate families, friends, professionals, and members of Muslim community. Often seen as a very generous way of saving a life, organ donation through transplantation is also a very powerful gesture of “gift exchange” embodying strong social and cultural meanings. In this paper, I want to posit that the subject of organ donation and transplantation in Islam is an unresolved matter. The subject of organ donation and transplantation has Religions 2021, 12, 576 3 of 16

been exceedingly contested within Islam and a ubiquitous consensus is absent. Further research and more robust academic and sociological debate are needed, not only to resolve the question of organ donation and transplantation in Islam, but to do so on the basis of a mature and analytical understanding of different perspectives and issues surrounding the phenomenon. Various sensitive and complex issues are intertwined with the debate on organ donation and transplantation and when employing the authority of the Qur’an, hadiths, and shari’ah in addressing the question of organ donation and transplantation, the matter of interpretation and the existence of multiple Islamic responses to the topic become appar- ent. With no central authority in Islam, a huge internal sectarian, and theological and ideological division in the ummah, a general consensus on matters of organ donation and transplantation is difﬁcult to locate. Contemporary Muslim scholars and jurists use ijtihad (independent scholarly reasoning or juristic interpretation) to deliberate on the matter, and there is more than one ijtihad or one set of ijtihads in existence. Thus, the central thesis of this paper is that, as organ donation and transplantation in Islam takes place within a multidimensional framework, there remains no conﬁrmed resolution regarding permissibility or impermissibility of organ donation and transplantation in Islam. The paper proceeds to demonstrate this with a discussion of two key Islamic perspectives on organ transplantation, one in its favour and another against it, and facilitates the reader to draw an informed conclusion.

2. Definition Organ is a term derived from Greek organon meaning implement or a tool for making or doing something. Transplant is a process of moving or transferring someone or something from one location to another. The combination of the two terms organ and transplantation, or organogenesis as it is known in medical and biological sciences, produces the meaning of moving an organ or tissue from one location in the body to another, from one body to another, or from an animal body to human body. In medical terms, organ transplantation is a surgical procedure involving the removal of a failing or damaged organ caused by refractory disease or injury from the human body, and replacing it with a working organ retrieved from a deceased or living donor. According to Al-Bar and Chamsi-Pasha “Organ donation is the donation of biological tissue or an organ of the human body, from a living or dead person to a living recipient in need of a transplantation” (Al-Bar and Chamsi-Pasha 2015, p. 209). Loeb offers a more detailed definition of organ transplantation, stating: By transplantation we understand the complete or partial separation of a piece of tissue, or of a part of an organ, or of a whole organ, from its normal connection and its transfer to a different place, either in the same individual (autotransplantation), or in a closely related individual (syngenesiotransplantation), or into another, not directly related individual of the same species (homoiotransplanta- tion), or into an individual belonging to a different species or class of animals (heterotransplantation, in the wider sense). The joining together of two organisms also may be considered as transplantation (Loeb 1930, p. 547). Organ transplantation is a medical procedure conducted by a specialist or a team of specialists. The individual from whose body the organ is retrieved is called the donor and the person in whose body the organ is transplanted is known as the recipient. The organ or organs may be procured from living donors, cadavers, or even an animal source. In some instances, with the technological innovations and advances made in medical science, artificial organs are being used, too. Transplanted organs can be artificial or natural and can be whole such as a kidney, heart, and liver, or partial such as heart valves, skin, and bone. In modern medical professions, organ or tissue transplantation is promoted as a disease cure-source and an effective lifesaving procedure, offering the recipient the opportunity for an improved and enduring quality of life. Today, the following organs and tissues can be successfully transplanted: Religions 2021, 12, 576 4 of 16

• kidney; • liver; • heart; • lung; • skin; • pancreas (e.g., the islets of Langerhans); • intestine; • bone; • cornea; • middle ear; • bone marrow; • heart valves; • connective tissue (Al-Bar and Chamsi-Pasha 2015). In modern medicine, three types of organ transplantation are practiced. Autograft or autotransplantation, which is a surgical procedure wherein an organ, a tissue, or sometimes both from one part of the body is transplanted to another part in the same individual, for example, in the body from the trunk to the arm. Allograft or allotransplantation is a transplantation process of organs, tissues, or cells from a genetically non-identical donor of the same species to a recipient, for instance, a heart from Mr White to Mr Blake. Most human organ and tissue transplantations in modern medicine are allografts. Xenograft or xenotransplantation is a surgical procedure where organs or tissues are removed from one living species to another, for example, a heart valve removed from a monkey and transplanted to a human.

3. Organ Transplantation in History Contrary to popular belief, organ transplantation is not a novelty of the modern world. It is often thought that tissue and organ transplantation within the overall medical advancement has a rather short history, but historians note that medical professionals and surgeons have been trying to restore lost or mutilated body parts centuries before the modern organ transplantation inventions (Hamilton 2012). Barker and Markmann(2013, p. 1) claim that “The idea of replacing diseased or damaged body parts has been around for millennia”. The ﬁrst detailed description of repairing defects of nose and ears using autografts from close by skin and surgically replacing the damaged nose is found in an ancient Sanskrit text on medicine and surgery called the Susruta Sanhita (circa 600 B.C.) (Filliozat 1964; Zhorne 1985). Using elegantly described surgical procedures for nose and ear transplantation in the Susruta Sanhita, medieval Muslim surgeons, and subsequently the Italian surgeon Gaspare Tagliacozzi (1545–1599), and then, in the seventeenth and eighteenth centuries, the British surgeons training in India, expanded and developed organ transplantation procedures (Al-Bar 1996). Ancient Egyptian, Greek, Roman, and North and South American surgeons transplanted teeth, and Arab medical practitioners mastered this technique over a millennium ago (Peer 1955; Kee 1986). In the 1800s, tooth transplant-related activity attracted public attention in France, and in the 1920s, skin and “monkey gland” transplantation put a new spotlight on surgeons (Seghers and Longacre 1964). By the 1960s, medical practitioners gained a new high status on the back of their successful innovative organ grafting procedures. People were simply astounded with the prospect of xenotransplantation success, where surgeons were to remove diseased organ in a human and replace it with pig organ. Moreover, they were captivated by complex arm, leg, and face transplants, and enthralled by the possibility that surgeons could grow organ from stem cells in laboratories. However, it was not until around the middle of last century in 1950s that organ transplantation procedures showed signs of greater success when surgeons were able to successfully graft an organ from person (donor) to person (recipient) (Hamilton 2012). Before this, human-to-human, organ grafting was perceived as an impossibility as the human body, with some rare exceptions, almost always rejected the grafting of an organ Religions 2021, 12, 576 5 of 16

procured either from humans or animals. When surgeons could not positively respond surgically or pharmacologically to this reaction against foreign tissue across the entire animal family, any hope to succeed in such an endeavour was given a serious blow. Many members of the medical fraternity came to respect the persistent and pervasive power of the body to fight against foreign tissue, and realised that to intervene in “nature” was not going to yield a positive outcome. However, there were some who later became the pioneers in organ transplantation by persisting with their mission, facing massive biological challenge, as well as peer resistance and sometimes even aggression, along the way (Hamilton 2012). It is true that what the pioneers of organ transplantation achieved in the 1950s and 1960s is considered precious and admirable, though it was not the case during the initial period. Recognition of the pioneering work took place slowly, but it was eventually recognised as one of clinical medicine’s grandest contributions. Those pioneers laid an important and strong foundation for the future of organ transplantation, and “By the end of the twentieth century, clinical success with organ transplantation between humans was almost complete, having reached the status of a routine, noncontroversial service” (Hamilton 2012, p. XIV). Some historians have suggested that activities of organ transplanters prior to 1940s were “prescientific” or antiquated (Klasen 2011; The International Encyclopedia of Surgery 1881). As science and medicine were not as advanced at the time as they later became, there can be some truth in such a claim; however, there is no denying that early works were pivotal to the overall and future success of organ transplantation as we know it today. In the last fifty years, the world has witnessed some major advances in the field of medical research, many of which resulted in actual clinical applications. Generally speaking, these applications have produced tremendous benefits to patients, with life- changing results. As a vast majority of these new clinical applications are novel, they often generate controversy and raise new ethical questions. One such advance is solid organ transplantation, which has created and continues to create concerns around ethics, morality, and law. Fox asserts that: Transplantation and dialysis, in a dramatic, somewhat magnified form and with nuances of their own, present virtually the whole range of medical, ethical, legal, social, cultural, and psychological problems that classically accompany medical experimentation with human subjects and the process of therapeutic innovation. ... These procedures have also given rise to a set of more unique phenomena, associated with certain values, beliefs, and attitudes that have basic symbolic or sacred meaning in modern society (Fox 1970, p. 406). Organ transplantation, no doubt, has become a very useful and valuable form of treatment, particularly for end stage of kidney, liver, and heart failure. The success of transplantation is measured by the survival of the transplanted organs and the patients. Kidney failure excepted, organ transplantation is the only form of possible treatment for organ failure such as the liver and heart. Solid organ transplantation has increased over the years due to its general success, the reason being that the ability to control the transplant patient’s immune response has improved. Heinemann says that: With the development of cyclosporine and related improvements in immunosup- pressant therapies, the threat of transplant rejection has dramatically declined, and demands for transplantable organs now consistently outweigh any increases in their availa1ility (Heinemann 2008, p. 76). As a result, there has been a reduction in the incidence of acute graft loss and the side effects of immunosuppressive regimens, affording transplant surgeons heightened confidence and mobilising them into areas of structural non-life-threatening defects surgery and transplantation. It is due to this expansion in transplantation practice that we have seen an increase in transplantation of hands and other body parts. These are reconstructive transplants, however, and must be treated separately from the more complex organ transplantation. Religions 2021, 12, 576 6 of 16

Nuances of Organ Transplantation Practise in Muslim History Although Islamic scripture is silent on the issue of organ transplantation the historical documents (Al-Bar 1996; AlNawawi n.d., p. 293; 1978, p. 190; Asshirbini n.d.) reveals that Muslim surgeons practised organ transplantation throughout Islamic history going all the way back to Prophet Muhammad’s time (Hawa 1971). It has been reported that, during the prophetic career of Muhammad (570–632), a companion of his—Qatada ibn Nu’man— damaged his eye in the battle of Uhud, and Prophet Muhammad himself replanted it, which functioned better than the other, normal eye (Hawa 1971, p. 97). In another instance, it has been related that, in the battle of Badr, Prophet Muhammad replaced the damaged arm of Muawath bin Afra and the impaired hand of Habib bin Yasaf (Asshibani n.d., p. 244). Asshirbini(n.d., pp. 190–91). In his book, Mughni, Al Muhtaj discusses extensively the bone implantation practised by early Muslim surgeons in all three key forms—autografting, allografting, and xenografting. It is known that “Muslim jurists sanctioned transplantation of teeth and bones, which had been practiced by Muslim surgeons for over a thousand years” (Al-Bar and Chamsi- Pasha 2015, p. 210). Muslim surgeons relied on juristic provisions and support to Islamically legitimise their practise. The practise, however, was rare, on a very small scale, and not in the way it is performed today. “Transplantation of human organs, as is practised today, was certainly unknown to the classical Muslim jurists” (Ebrahim 2001, p. 49).

4. Two Key Islamic Perspectives on Organ Transplantation Islam is said to be a din wa-dawla (religion and the state) which existed and spread as a community-state under the central authority of the caliphate. Although the caliphate was not a perfect socio-political system, it nevertheless operated as a central governing system, attempting to cater for all its citizens in all spheres of life. Ira Lapidus(2014) notes that, in comparison to contemporary period, Islam and Muslims were much less diverse, particularly during the “Islamic Golden Age”, and the nature of the society was religious and not secular. For example, under the Abbasids (750–1517) initiatives were developed to bring about a greater Islamic unity by encouraging a greater level of cooperation between different Muslim sects and mosques divided by doctrine, theology, and practice. Abbasids also promoted Islamic ecumenism—the idea of single people, that is, the unity of the ummah. Even during the existence of Ottoman Empire (1299–1922), Safavid Empire (1501–1736), and Mughal Empire (1526–1857), when these sovereignties operated independently and sometimes against each other, within them was still some semblance of central authority and uniformity which cannot be found in the Muslim world today (Esposito 2000). Although there was some variation in the implementation of the law and the application of Qur’anic instructions, the religion, nevertheless, played an important role in the government, law, and social organisation of society (Nasr 2003). The decision-making machinery was moderately consistent, the Muslim population was less diverse and varied, and Muslims enjoyed a real sense of ummah (community of believers) (Lapidus 2014). The development of Islam and state institutions, such as the caliphate (Islamic state), law, education, health, the military, social services, judiciary, and the bureaucracy, were intertwined. The caliphate, or state leadership, established the pattern for the organisation and administration of the state activities. Islam was the source of state, theology, ideology, identity, unity, and solidarity. The political, military, judicial, and ﬁscal control of the Muslim community was managed from the top—the leadership. The state leader—caliph— was elected through the process of consultation, nomination, and selection by the shura (consultative committee) who, after pledging their allegiance, presented the caliph to the community for approval by public acclamation. During the heyday of Islam and when Islamic states existed, Muslim rulerships would govern large geographical territories and socio-economic, religious, and political decisions would ﬂow from the central authority, which would issue instructions on religious and worldly matters, often in consultation with the scholars and jurists. However, with the Religions 2021, 12, 576 7 of 16

official abolition of the Ottoman Empire in 1922, the last bastion of Islam, Islam and Muslims lost their central authority, and thus was produced a crisis of religious authority. One of the consequences of this is that the global Muslim community, today, is very diverse and divided along national, ethnic, parochial, sectarian, theological, and ideological lines, and so who speaks for Islam and represents the Muslim community is a very open question. In relation to the discourse about organ donation and transplantation in Islam, there are extremely technical, varied, and diametrically opposite positions on the matter. A single consensus on organ donation and transplant in Muslim societies or in the Muslim world does not exist; the subject, therefore, is a highly contested one. It is not the aim of this paper to examine differing positions exhaustively and in detail individually, however the paper will concentrate on two distinct prevailing schools of thought under which organ transplantation is generally discussed by scholars in contemporary Muslim communities. Before proceeding, it is worth reiterating that two great texts of Islam—Qur’an and hadiths, are silent on the issue of organ donation and transplantation. In Islam, every human life is very valuable and, therefore, killing (any unlawful death) a person is akin to killing the entire humanity and saving a person is comparable to saving the entire humanity. The Qur’an says “And do not kill the soul which God has forbidden [to be killed] except by [legal] right” (6: 151). The high value that Islam places on human life and the significance of preserving life is integral to Islamic faith, legal system, and ethics (Hamdy 2012). Human life in Islam is treated equally, and there is no privileging of Muslim life or discrimination against non-Muslim life. Qur’an sates, “And We have certainly honoured the children of Adam and carried them on the land and sea and provided for them of the good things and preferred them over much of what We have created, with [definite] preference” (17: 70). Here, we can see that Islamic religion describes all human beings as “children of Adam”, naturally excluding any discrimination or prejudices based on race, colour, sex, or belief, and bestowing upon humans equal rights and universal dignity. Muslims believe that they have a special relationship between the self and the body. It is an important principle in Islam born out of the belief that the God is both the Creator and the Sustainer of human life. It is He who gives life and Who takes it. Life and death are in His exclusive hands. Except under the hudud crimes (Criminal Law), no person or authority has the right to end a human life (Hassaballah 1996). As human life is precious in Islam, so then is equally precious the human dignity, including the dignity of a diseased body (Sachedina 2009). According to Islamic teaching, human beings neither have absolute control over their lives nor ownership over their bodies. As such, humans must take all the precautions and every step to preserve body-inviolability. Contemporary Muslim scholars and jurists employ legal source or jurisprudential tool known as ijtihad (there are five sources of law in Sunni Islam—Qur’an, hadith, qiyas (ana- logical deduction), ijma (scholarly consensus), and ijtihad (independent scholarly reasoning or juristic interpretation)) (Kamali 2008)—to deliberate on the issue of body-inviolability or, more broadly, on the issue of organ donation and transplantation. As the two great texts of Islam are silent on the issue, Muslim scholars and jurists start their discussions based on the assumption that their deliberations on the issue of organ donation and transplantation are “informed” and undertaken in “good faith”, which God, in His infinitive wisdom, will endorse. Abul Ebrahim remarks that “Contemporary Muslim jurists have deliberated on the issue and proposed certain juristic guidelines based on deductions from the broad teachings of the two original sources of the Shar¯ı‘ah, namely, the Qur’an¯ and the Sunnah” (Ebrahim 2001, p. 51). They use Qur’an and Hadith to explain related concepts and abstract topics, such as transplanting God’s property or ownership of the human body (Aramesh 2009; Hamdy 2012), human dignity (Hamdy 2012), body intrusion or prohibition of mutilation (Ebrahim 1995), and human rights (Kamali 1993) for deliber- ative purposes. Marcotte says that “Some have noted that religious proofs based on the Scriptures (Qur’an and hadiths) or on Islamic principles have been used to argue both for and against particular positions” (Marcotte 2010, p. 33). Religions 2021, 12, 576 8 of 16

These are complex and abstract concepts requiring critical analysis and careful de- liberation and, given scholars’ own understanding and perspectival proclivity, there are inevitably many interpretive challenges as well as plural interpretations. Hurst attests stating: There is no single consensus on organ transplant in the Islamic community; this is not entirely surprising. In Islam, there is no papacy, as in the Roman Catholic Church, to articulate dogma on certain contentious matters. While legal opinions (i.e., fatwas) may be sought about controversial or contemporary issues from Muslim scholars who are acknowledged experts in matters of Islamic law and ethics, these still may profoundly differ based upon the scholar’s interpretation of the authoritative texts (Hurst 2016, p. 3). Thus, in a decision-making process based on the directives of interpretation and Islamic legal maxims, the scholars and jurists exercise their legal discretionary powers (ijtihad) (Moosa 1998) to arrive at a decision and, as a result, the prevalence of multiple opinions on organ donation and transplantation. According to some scholars, the two prevailing positions on organ donation and transplantation are geographically and nationally divided. For instance, Oliver et al., says in regard to Indo-Asian and Arab Muslim scholars that “Of note, there appears to be some discrepancy between Indo-Asian and Arab Muslim scholars in that the former are often less approving of organ donation” (Oliver et al. 2011, p. 438). This dichotomisation may raise some questions due to the complex internal diversity in each of these two regions. However, to diminish the importance of geographical or regional differences is academically precarious. Hughes explains: Geographic differences are certainly important in Islam. But also important are the numerous legal schools and their interpretations. Since Islam is a religion predicated on law (sharia), variations in the interpretation of that law have contributed to regional differences (Hughes 2016). Therefore, perhaps a more plausible geographical and national divide can be drawn between the subcontinent, not Indo-Asian, Muslim scholars, particularly from Hanafi school of jurisprudential-based (it is one of the most dominant of the four Sunni schools of religious law) Deoband seminary, which is the largest seminary in the subcontinent, and Arab Muslim scholars, many of whom follow one of the following Sunni legal schools—Shafi’ism, Malikism, and Hanbalism. Thus, it can be said that the Muslim scholars and jurists who are located in the Arabic speaking part of the world, who are thought to give priority to living over spirituality and take an anthropocentric view, generally consent to the permissibility of organ donation and transplantation. Various examples are testimony to this assertion. In 1959, Sheikh Hassan Mamoon, the then Grand Mufti of Egypt offered the first fatwa in the modern times endorsing organ donation, sanctioning corneal transplantation from cadavers and from those who consented to organ donation upon their death (Fatwa No. 1084 dated 14 April 1959) (Dar Allfta Almisryah 1982). In 1982, the Supreme Council of the Ulama in Riyadh, Saudi Arabia, approved organ harvest and transplantation when considered medically necessary (Report of the Senior Ulama Commission 1982, p. 46). In 1986, the Islamic Fiqh Council of the Organisation of the Islamic Council in Amman, Jordan delivered a ruling (ruling no. 3/07/86) in favour of organ donation, both from a cadaver and living person (Al-Bar 1996, p. 109). In 1988, the resolution reached by the International Islamic Fiqh Academy of Jeddah (IIFA) led to the Saudi Government officially endorsing organ transplantation (Ali and Maravia 2020). Those living particularly in the subcontinent where around a third of Muslim population reside, it has been said, argue that spirituality takes priority over living, and harbour a theocentric view, therefore subscribing against organ donation and transplantation. This position is reflected in the following examples: In the late 1960s, a number of Pakistani scholar-jurists with links to Deoband Seminary arrived at the decision that organ transplantation was not permissible in Islam (Moosa 2002); “None is owner of his life and parts Religions 2021, 12, 576 9 of 16

of the body, therefore neither can he sell it nor can gift to anyone. Such dealings are wrong and invalid” (Darul Ifta 2020, Fatwa: 1138/982=B/1429); organ giving and receiving are prohibited, “This opinion was held by Muh. ammad Shafι (d. 1976), former chief muftι of Darul Uloom Deoband India” (Ali and Maravia 2020, p. 4); and Muhammad Shafi Uthmani, former Grand Mufti of Pakistan, advised against organ transplantation as it is a process which undermines the station of human beings in the divinely created universal system, saying: God Most High has created the entire universe and creation for the benefit and use of the human being, and the human being has been created as the master and consumer of the entire universe. The following Quranic verses are evidence of this point: “And verily we have honored the children of Adam,” and “He has created for you all that is on the earth” (Uthmani 1967, p. 30). It can be posited that the rationale for two separate positions on organ transplantation in Islam continues due to different sets of rationalisation offered by the two opposing schools of thought. The subcontinent Muslim scholars are largely influenced by Deoband seminary which is based on Hanafi school (Warren 2013) observes that Hanafi school of jurisprudential thought have always been deemed among the most flexible, liberal, and rational in Islamic law) of jurisprudence, and is very influential in south and central Asia (Moj 2015). Theologically, the Deobandis subscribe to the doctrine of taqlid (conformity to legal precedent), and are relatively free from any state influence, despite being located in world’s largest democracy—India. Deobandis have their own worldview based on their own interpretation and understanding of Islam, and remain aloof from modern value-system. Arab Muslim scholars, however, are very diverse, particularly jurisprudentially, and are vulnerable to state influence and intervention. In the Arab world, there is at least some level of interaction between the state and religion and, as states are modern nation- states, the influence and dominance of modern worldview is pervasive. Brown explains as follows: What is unusual in the Arab world is not the public role of religion but the extent and range of that role. ... But as the process of state formation began across the Arab world during the nineteenth and twentieth centuries, in each place it developed differently. As a consequence of this, official religious institutions evolved quite differently as well. In its particularities—and even in many of its most general features—this evolution was rooted substantially in the process of modern state formation. Indeed, state formation and the organization of religion have gone hand in hand, . . . The commonalities among Arab states are straightforward. Most grant Islam official status, have institutions that offer advisory interpretations of Islamic law (fatwas), administer religious endowments and charities, oversee mosques, and apply some version of Islamic family law. State muftis are largely a nineteenth- and twentieth-century innovation. It was then that states began appointing such religious officials and establishing a designated bureaucracy for issuing legal interpretations, at times to replace or expand upon the Ottoman religious bureaucracy (Brown 2017, pp. 4–5). As organ transplantation in the modern world is heavily dictated by modern worldview, and Arab Muslim scholars are under direct modern state influences in their respective countries, it can then plausibly be argued that Arab Muslim scholars are vulnerable to a modern worldview which has direct consequences to their decision making about organ transplantation. It is perhaps why there is a distinction in viewpoints about organ transplantation between subcontinent Muslim scholars and Arab Muslim scholars. Religions 2021, 12, 576 10 of 16

4.1. Organ Donation and Transplantation Are Permissible Those Muslim scholars and jurists who are in favour of organ donation and transplantation have declared that organs, either from a live or dead body, can be transplanted to a patient in end-stage organ failure. They arrive at this decision using legal discretion (ijtihad) in the absence of any scriptural evidence or directives. Additionally, they determine the divine intent when making decisions for organ donation and transplantation by combining various contrasting themes found in the Qur’an and hadiths. These include the necessity to save one’s life, the encouragement to save another’s life, human dignity and respect, and altruism. They do this by building their argument on the assumption that, although the Qur’an and hadiths are silent on the issue, the scriptural overarching teaching supports organ donation and transplantation, or to put it another way, that organ donation and transplantation does not violate scriptural edification. How? They do this by resorting to the shari’ah to work out the benefits of organ donation and transplantation to human life. As for others, to them the basic function of shari’ah is to protect the interest of people against harm and, therefore, benefits are harmonised with the higher objectives of shari’ah known as maqasid al-shari’ah. Maqasid al-shari’ah is an Islamic legal doctrine which often works in conjunction with another related classical doctrine known as maslaha (welfare or benefit or public interest), and together they aim to advance the preservation of five essentials of human well-being aptly embodied in the daruriyyat (necessary) category of benefits. Muslim legal experts have organised the entire range of benefits or interests into three categories: i daruriyyat (necessary) which is enumerated at five, namely protection of faith, protection of life, protection of progeny, protection of intellect, and protection of property; ii hajiyyat (complementary); iii tahsiniyyat (embellishments). For Muslim scholars and jurists who are in favour of organ donation and transplantation, organ transferring does not violate but, in fact, clearly complies with one of the five essentials of human well-being, that is, the preservation of life. Thus, they present organ donation and transplantation as a welfaristic and altruistic process and fulfilling the requirement of the preservation of human life. Violation of human body, either in living or cadaveric state, is prohibited in Islam. The human body is considered to be sacred in Islam, and in hierarchy of creations is given a high status as God’s special creation. Whether living or dead, the human body enjoys a special honour and is inviolable in Islam. Life is also considered precious in Islam, as in any cultural tradition, and saving it is recognised in the Qur’an as an act of altruism. In this regard the Qur’an says, “Whosoever saves the life of one person it would be as if he saved the life of all mankind” (5: 32). Organ transplantation proponents read these Qur’anic verses as a directive to make every effort to preserve human life, which is highly rewarding, and also as evidence that the sanctity of life overrides all other considerations. In other words, they construe these verses to be a command from God to preserve life. They also posit that saving life is necessary and therefore determine the permissibility of organ donation and transplantation by using the legal terminology to establish patient’s darura (necessity) condition when unlawful (haram) can become lawful (halal). They rely on the following Qur’anic verses: He hath only forbidden you dead meat, and blood, and the flesh of swine, and that on which any other name hath been invoked besides that of Allah. But if one is forced by necessity, without wilful disobedience, nor transgressing due limits, then is he guiltless. For Allah is Oft-forgiving Most Merciful (2: 173). Whether it is an act of altruism or necessity, is it a body-violation when an organ is harvested from either a cadaver or living body, and is it also a body-violation to cut open a patient for the purpose of organ transplantation? In this dilemma, the maxim that reconciles the two, according to the organ transplantation proponents, is “necessity overrides prohibition” (al-darurat tubih al-mahzurat). They rely on this to build their ar- Religions 2021, 12, 576 11 of 16

gument in favour of organ donation “and claim that according to the shar¯ı’a one had in certain circumstances to choose the ‘lesser of two evils’” (Heyd 1993, p. 48). They see organ transplantation as a way of eliminating harm by taking an organ from a cadaver or living body and transplanting it in a patient, leading to the saving of a life. Here, the doctrine of choice is applied—if forced to choose then “choose the lesser of the two evils”. As for the cadaver more specifically preventing harm takes priority over preserving the body of the deceased and the canon of the “conflict of interests” or maslaha is used—when faced with two conflicting interests, “let the one which will bring greater benefit take precedence”. There are also traditions attributed to the Prophet Muhammad that organ transplantation proponents understand to be supportive of organ donation and transplantation. For instance, Usamah ibn Sharik narrated: The desert Arabs then came from here and there. They asked: Apostle of Allah, should we make use of medical treatment? He replied: Make use of medical treatment, for Allah has not made a disease without appointing a remedy for it, with the exception of one disease, namely old age (Al-Sijistani n.d., p. 3846). Organ transplantation proponents argue that this hadith is a testimony that God has made a cure for every disease, and organ transplantation is a cure for a diseased or failing organ. They say that here is an Islamic teaching that encourages believers to find cures for their illnesses and leave the ultimate success to God. Replacing a failing organ with a properly working organ which cures the body of dysfunction is similar to taking medicine to permanently eradicate an ailment such as gallstones. The recommendation is that Muslims should try and find suitable medical solutions to their health problems, including organ transplantation, as a solution and not be fatalistic. This is their responsibility. Another example is: Abu Huraira reported: The Messenger of Allah, peace and blessings be upon him, said, “Whoever relieves the hardship of a believer in this world, Allah will relieve his hardship on the Day of Resurrection. Whoever helps ease one in difficulty, Allah will make it easy for him in this world and in the Hereafter (Muslim n.d., p. 1508). This Prophetic tradition has often been considered as supporting organ donation and transplantation, as it underpins the charitable goodness connected to such acts of benevolence. It is seen as something God loves as humans try to mitigate each other’s agony and sorrow. Organ donation relieves hardship for those who are in pain and under duress. Donating an organ such as a kidney to someone whose kidney is damaged is viewed as an act of altruism and kindness worthy of great reward from the mighty God in this world as well as in the Hereafter.

4.2. Organ Donation and Transplantation Are Prohibited Islamic scripture contains numerous principles that can be used to denounce organ donation and transplantation. Those scholars and jurists who take a prohibitive stance against all or some form of organ donation and transplantation, who cite the authoritative sources within Islam, make equally as compelling arguments as their counterparts (Rady and Verheijde 2009, p. 882; Rady et al. 2009, p. 175). One of the premises upon which these scholars and jurists base their argument against organ donation and transplantation is the Islamic principle of self-body nexus. As mentioned earlier, one can ﬁnd in Islam a great value is placed on human life. The preservation of life is an integral part of Islamic faith and, as such, Islam treats the body and soul, or the self–body interconnectedness, with great care and reverence. It is for this reason that Muslims not only believe that there is a special relationship between the self and the body, but treat the self and the body as one and with great sensitivity and veneration. Religions 2021, 12, 576 12 of 16

The scholars and jurists who stand against organ donation and transplantation often relate to the Qur’anic teaching that the body is a gift from God and, therefore, an individual does not have an ownership claim over the body. The “individual” or the “person” is the body and the soul which together as one is a “gift” from God, therefore, a human does not own himself/herself at all. If anything, humans have only a custodianship or “stewardship” (Sachedina 2009) claim over their bodies. This kind of conceptualisation of the person is in contrast to the idea of the person in modern secular thinking where the person is an individual believed to have independence and the ability to make all decisions relating to life alone and is the owner of his/her body, thus, his/her self. Under impermissibility stance for both donating and receiving organs, the rationale is that, as human beings do not have ownership over their bodies, bodies are sacred and mere amanah (trust) endowed by God to humans. In the Qur’an, Allah mentions that He has endowed humans with all they require in respect to bodily organs (Qur’an, 90: 8–9). “This understanding would lead one to infer that man has no right to donate any of his organs since these organs are not in reality his own, but have rather been given to him as an amanah¯ (trust)” (Ebrahim 2001, p. 53). The human body is seen as a unique gift and “The Trust” from Allah and is His “property”, over which human beings have only responsibility and not ownership. Based on this understanding of the body, organ transplantation is seen as a violation of human dignity (hurama wa karama) and thus sacrilegious infringing the bestowed trust and body-sacredness. A ruling permitting organ donation and transplantation will cause incalculable harm to human dignity and, therefore, such a practise is inexcusable (Moosa 1998). Additionally, as saving the life of the recipient will involve either an act of aggression against the human body (which is a harm) or if it is a living donor putting him or her go through physical pain during surgery (which is a harm) organ transplantation is impermissible for “harm cannot be reduced by another harm”. In regard to the cadaver, particularly any process of harvesting the organs from it violates the sanctity of it. The violation of the sanctity of the cadaveric body, according to the scholars and jurists in this category, is forbidden in Islam. In this regard a Prophetic Tradition is often referred to which says: “Breaking the bones of a corpse is similar to breaking the bones of someone who is alive” (Al-Sijistani n.d., p. 3207). Ebrahim notes that: It is true that Islam forbids any act of aggression against human life as well as the body after death. Thus if one were to take an organ out of the dead man’s body so as to transplant it into another person, it could justiﬁably be argued to be tantamount to mutilation of the body and violation of the sanctity of the corpse (Ebrahim 2001, p. 55). Similarly, Marcotte explains: Jurists and religious scholars appeal to a central Islamic principle that forbids any alteration of God’s creation. Human beings and their bodies are ‘creations of God’ (khalq Allah). As creations of God, our bodies are, in a sense, not completely ours. The main reason for this remains that Islam upholds principles of sanctity (or inviolability) (hurma) and dignity (karama) of the human body, that embrace both the living and the dead (body), . . . (Marcotte 2010, p. 35). The self–body construct and body ownership argument is simple but interesting. It is a persuasive enough argument against organ donation and transplantation which was popularised by a famous Egyptian Sheikh, Muhammad Mitwalli al-Sha rawi,“ in the last decades of 20th century (Hamdy 2012). Sheikh al-Sha rawi“ advanced a simple but a dazzling argument which ran against the popular assumption that modern technological innovations have rendered Islamic teachings obsolete (Hamdy 2008) and captured the attention of Muslims from all walks of life. He argued that humans do not own their bodies; their bodies are a trust given to them from God. His argument highlights “the sacredness of human life, and the human body being a trust from God to be protected and the beneﬁt Religions 2021, 12, 576 13 of 16

for the public good” (Marcotte 2010, p. 34). Donating the body or its constituent parts will obviously breach this bestowed trust and is unacceptable. His argument was threefold, each based on the principle of Islamic belief: i human beings do not have the ownership rights over their bodies as if they were properties; ii death is uniting with Allah,; iii the self–body unity is achieved through piety and worship (Hurst 2016).

From Sheikh al-Sha rawi’s“ viewpoint organ donation and transplantation is irreverent and a clear violation of this trust. Hence, he aptly poses the question that “Humans do not own their bodies; how then can they donate or sell their organs?” (Ali 2019, p. 63). Sheikh al-Sha rawi“ relied heavily on the Qur’anic concept of suicide and its impermissibility to denounce organ donation and transplantation. Suicide is explicitly forbidden in the Qur’an as it says, “Do not kill or (destroy) yourselves: For verily Allah has been to you Most Merciful” (4: 29). In Islam, “Like life itself, the body acquires a type of ‘sacralised’ status. One cannot commit suicide or dispose of one’s life or one’s body as one pleases” (Marcotte 2010, p. 36). He deduced that suicide is an unauthorised premeditated cessation of life through freely interfering with one’s own body, and so places organ donation on the same level. As the Islamic scriptures does not explicitly address the subject of organ donation and transplantation, Sheikh al-Sha rawi“ and other contemporary anti-organ donation and transplantation Muslim scholars and jurists employ various principles in the scriptures to denounce organ donation and transplantation. From a legal point of view, “necessity overrides prohibition” (al-darurat tubih al- mahzurat) is not a sustainable premise for organ donation and transplantation. Using this principle to universally endorse all models of solid organ donation and transplantation is problematic from the viewpoint of Muslim scholars and jurists who do not support the practise, arguing that not all organ transplants are necessarily lifesaving. For example, kidney transplantation may not be an absolute necessity in light of existing alternative modalities of renal replacement therapy to preserve life, such as dialysis. Using such logic, Muslim scholars and jurists against organ donation and transplantation present an argument that tips the scale against the practise, and keep true to Qur’anic teaching which places a heavy emphasis on respect and sanctity of the human body (Haleem 2010). Thus, the scholarly and juristic formalism in the predilection of analogies and directives of interpretation of the darura (necessity) or a primary (life-threatening medical condition) need compel the opponents to organ donation and anti-transplantation to arrive at a determination that considers the practise impermissible. As a category, “necessity”, these opponents argue, is treated to be an exceptionally subjective notion by the medical experts and practitioners, but not so in a particularly formalised jurisprudential dogma the opponents themselves use and subscribe to. They, therefore, recommend that alternative to organ donation and transplantation, such as various artiﬁcial substitutes and reconstructive devices, should be explored, designed, and used.

5. Conclusions It is true that there are nuances of increasing acceptability of organ donation and transplantation in contemporary Muslim communities, but there still remains an aura of uncertainty about whether Islam considers organ donation and transplantation to be permissible. The uncertainty originates from ambiguity caused by conﬂicting opinions among contemporary Muslim scholars and jurists. The Islamic ethical concepts of au- tonomy, beneﬁcence, justice, and non-malfeasance are divided between theocentricism, anthropocentrism, and adherence to the shari’ah. The shari’ah is a religious law through which Allah guides His faithful believers to the “right way”. In the shari’ah, the “right way” denotes, among other things, giving Allah His due right—huquq-Allah—and giving individuals their right—huquq al-ibad. One guiding directive of Islam is the right to health, and a connection then can be made to the question of whether or not organ donation and transplantation is permissible in an attempt to preserve health. One way for the Religions 2021, 12, 576 14 of 16

contemporary Muslim scholars and jurists to address this is to employ ijtihad to determine the divine intent when making decisions for new situations which organ donation and transplantation is one of them. Many contemporary Muslim scholars and jurists believe that humans do not have ownership of their body and soul as one entity which is considered to be a gift from Allah. Human beings and their bodies are “creations of Allah” (khalq Allah) and, therefore, it is forbidden to alter His creation. Our bodies, then, in a sense, are not completely ours and are temporarily entrusted to us, by God, as an amana (trust). Additionally, Islam upholds principles of sanctity or inviolability (hurma) and dignity (karama) of the human body that not only applies to the living body but also the corpse. One could then argue that sanctity of human body strips humans of any rights over it giving the body a sacralised status. This status also applies to the deceased body and its sanctity, therefore the body must be preserved under any circumstance. Some scholars and jurists invoke the following Qur’anic verses “And do not pursue that of which you have no knowledge. Indeed, the hearing, the sight and the heart—about all those [one] will be questioned” (17: 36) to argue that there exists an eschatological need for the preservation of the body, as all body parts must be intact on the Day of Judgement and organ donation and transplantation, if carried out, would be an obstruction to any testimony. However, then there are some Muslim scholars and jurists who argue that, ethically, the noble act of donating an organ outweighs the necessary mutilation of a dead body, it serves as a form of altruistic service to fellow human beings, necessity overrules prohibition (al-darurat tubih al-mahzurat), and general gain counterbalances minor negative consequence. Relying on the following Prophetic teaching, “Whoever helps ease one in difﬁculty, Allah will make it easy for him in this world and in the Hereafter” (Muslim n.d., p. 1508), they posit that herein is the evidence in support of organ donation and transplantation. Furthermore, interactions and discussions between medical experts and practitioners of new medical surgical procedures and Muslim scholars and jurists who can better understand the process and perform their informed ijtihads are often lacking. Consequently, there is a disjointed response to new medical surgical issues. Additionally, medical experts and practitioners need to be cognisant, when discussing organ donation and transplantation with their patients, that Muslim scholars and jurists are not united on the matter and different interpretations and positions exist. This reveals that a variety of positions and opinions exist that govern organ donation and transplantation in Islam. The contemporary Muslim juridical culture is internally very diverse and Muslim scholars and jurists from different cultural and parochial con- texts, although using the same scriptural sources, end up making diametrically opposite determinations. Sociologically, this is not surprising, as modernity has brought about sweeping transformations in Muslim societies. Muslim societies which were, at one stage, relatively homogeneous in nature, and in which key institutions were linked with the central authority, as described above, are no longer socially organised, nor operate in that way. The introduction of new systems of analysis, modern education, new understanding, technologies of communication, the transformation of many Islamic and Muslim institutions, and the rise of electronic means of communication such as the Internet, have opened up the decision-making process and capacity. It is no longer the state or the institution that determines what is halal (permissible) and haram (impermissible) in Islam. Media Sheikhs (Muslim scholars), Muftis (Islamic scholars who are the interpreters or expounders of Islamic law), and Muslim jurists have become equally relevant and important as the central authority and the use of ijtihad (scholarly or individual reasoning) is forever more pervasive. For these and other reasons, organ donation and transplantation in Islam remains an unresolved issue. Both sides of the spectrum—pro-transplantation and anti-transplantation campaigners—mount equally forceful arguments in favour of their respective thesis.

Funding: This research received no external funding. Religions 2021, 12, 576 15 of 16

Institutional Review Board Statement: Not applicable. Informed Consent Statement: Not applicable. Data Availability Statement: Not applicable. Conﬂicts of Interest: The author declares no conﬂict of interest.

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